Prevalence and Treatment of Mental Disorders
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Kessler and colleagues (June 16 issue)1 report a dramatic increase in the rate of psychiatric treatment within general medicine from 1990 to 2003. They mention competing demands, but it is important also to emphasize the increased complexity and cost of integrating psychiatric treatment into primary care. Recent data from our pharmacies at Denver Health underscore this burden on a public health care system. Of all prescriptions written by our general internal medicine providers in the first quarter of 2005, 15 of the top 75 (ranked according to volume) and 13 percent of the total pharmacy acquisition costs are for medicines used to treat depression, anxiety, sleep disorders, or psychosis. Because our patients have limited access to long-term mental health services, general internists must treat psychiatric illnesses outside their areas of expertise. Given that the clinician's plate is overfilled with complex medical care, it is no wonder Kessler et al. found that psychiatric treatment within general medicine was substandard. Evidence-based guidelines for generalists and increased psychiatric access for the severely mentally ill are two important potential solutions to this crisis.
Thomas D. MacKenzie, M.D., M.S.P.H.
Steven J. Kolpak, M.D.
Philip S. Mehler, M.D.
Denver Health and Hospital Authority
Denver, CO 80204
References
Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352:2515-2523.
The authors reply: We would like to thank Dr. MacKenzie and colleagues for correctly emphasizing that multiple barriers — such as competing demands, distorted incentives, and increased costs and complexity1 — undermine the integration of psychiatric treatments into primary care. We agree that these structural and financial barriers, and not just deficits in the training of clinicians, probably explain the low rates of adequate treatment in the general medical sector. We concur with their suggestion that two important potential solutions to the problem include dissemination of evidence-based guidelines and increased access to mental health services, particularly for the severely mentally ill. In addition, we would like to emphasize that there needs to be expanded use of several models of collaborative care that have already been shown to improve the adequacy of primary care treatments and patients' clinical outcomes.2,3 However, we recognize that in order to achieve widespread use of these models, it will be necessary to overcome additional practical and ideological barriers as well as purchasers' concerns about their costs.4,5
Ronald C. Kessler, Ph.D.
Philip Wang, M.D., Dr.P.H.
Alan M. Zaslavsky, Ph.D.
Harvard Medical School
Boston, MA 02115
kessler@hcp.med.harvard.edu
References
Frank RG, Huskamp HA, Pincus HA. Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatr Serv 2003;54:682-687.
Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-1031.
Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-220.
Pincus HA, Hough L, Houtsinger JK, Rollman BL, Frank RG. Emerging models of depression care: multi-level (`6 P') strategies. Int J Methods Psychiatr Res 2003;12:54-63.
Wang PS, Simon G, Kessler RC. The economic burden of depression and the cost-effectiveness of treatment. Int J Methods Psychiatr Res 2003;12:22-33.
Thomas D. MacKenzie, M.D., M.S.P.H.
Steven J. Kolpak, M.D.
Philip S. Mehler, M.D.
Denver Health and Hospital Authority
Denver, CO 80204
References
Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352:2515-2523.
The authors reply: We would like to thank Dr. MacKenzie and colleagues for correctly emphasizing that multiple barriers — such as competing demands, distorted incentives, and increased costs and complexity1 — undermine the integration of psychiatric treatments into primary care. We agree that these structural and financial barriers, and not just deficits in the training of clinicians, probably explain the low rates of adequate treatment in the general medical sector. We concur with their suggestion that two important potential solutions to the problem include dissemination of evidence-based guidelines and increased access to mental health services, particularly for the severely mentally ill. In addition, we would like to emphasize that there needs to be expanded use of several models of collaborative care that have already been shown to improve the adequacy of primary care treatments and patients' clinical outcomes.2,3 However, we recognize that in order to achieve widespread use of these models, it will be necessary to overcome additional practical and ideological barriers as well as purchasers' concerns about their costs.4,5
Ronald C. Kessler, Ph.D.
Philip Wang, M.D., Dr.P.H.
Alan M. Zaslavsky, Ph.D.
Harvard Medical School
Boston, MA 02115
kessler@hcp.med.harvard.edu
References
Frank RG, Huskamp HA, Pincus HA. Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatr Serv 2003;54:682-687.
Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-1031.
Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-220.
Pincus HA, Hough L, Houtsinger JK, Rollman BL, Frank RG. Emerging models of depression care: multi-level (`6 P') strategies. Int J Methods Psychiatr Res 2003;12:54-63.
Wang PS, Simon G, Kessler RC. The economic burden of depression and the cost-effectiveness of treatment. Int J Methods Psychiatr Res 2003;12:22-33.